Nursing Patient With Central Airway Stenosis Complicated by Tracheo-mediastinal Fistula.

The purpose of this paper is to summarize the nursing experience of a patient who developed a tracheo-mediastinal fistula following bronchoscopic balloon dilation for severe central airway stenosis due to tuberculosis. Key nursing points include: early recognition of complications; enhanced monitoring of the patient's condition to watch for recurrence of the fistula; dynamic monitoring of the circulatory system to prevent obstructive shock; evidence-based and standardized care for indwelling catheters; meticulous management throughout the course of treatment to eliminate mediastinal and subcutaneous emphysema; monitoring thrombus detachment and appropriate anticoagulant therapy; improving discharge guidance and continuous nursing. After effective treatment and careful nursing, the patient made a full recovery and was discharged smoothly.

A case report of percutaneous intramyocardial septal radiofrequency ablation in an adult with re-obstruction after Morrow procedure.

Background: Some patients with hypertrophic cardiomyopathy (HCM) re-occur with drug-refractory symptoms but are not eligible for re-operation after the Morrow procedure. Traditional treatment options are limited. We present the first case of the use of ultrasound-guided percutaneous intramyocardial septal radiofrequency ablation (PIMSRA) for the treatment of a patient with HCM combined with congenital anatomically corrected malposition of the great arteries (MGA) after Morrow procedure. Case summary: A 61-year-old male patient with congenital MGA, who had been treated with the Morrow procedure for HCM, had worsening symptoms in recent years that were difficult to control medically. He was diagnosed with occult obstructive HCM by stress echocardiography. After multi-disciplinary discussion, this patient was treated with PIMSRA. The post-operative clinical outcome was remarkable, with a significant decrease in septal thickness and disappearance of the left anterior branch conduction block. Conclusion: Percutaneous intramyocardial septal radiofrequency ablation is feasible and can be one of the options for the treatment of patients with HCM, especially those who cannot choose Morrow procedure. However, it still needs a large sample of clinical trials to validate its clinical effectiveness.

Comparison of periprocedural and procedure room times between moderate sedation and monitored anesthesia care in interventional radiology.

Objectives: In recent years, there has been increased utilization of monitored anesthesia care (MAC) in interventional radiology (IR) departments. The purpose of this study was to compare pre-procedure bed, procedure room, and post-procedure bed times for IR procedures performed with either nurse-administered moderate sedation (MOSED) or MAC. Material and Methods: An institutional review board-approved single institution retrospective review of IR procedures between January 2010 and September 2022 was performed. Procedures performed with general anesthesia or local anesthetic only, missing time stamps, or where <50 cases were performed for both MAC and MOSED were excluded from the study. Pre-procedure bed, procedure room, post-procedure bed, and total IR encounter times were compared between MAC and MOSED using the t-test. The effect size was estimated using Cohen's d statistic. Results: 97,480 cases spanning 69 procedure codes were examined. Mean time in pre-procedure bed was 27 min longer for MAC procedures (69 vs. 42 min, P < 0.001, d = 0.95). Mean procedure room time was 11 min shorter for MAC (60 vs. 71 min, P < 0.001, d = 0.48), and mean time in post-procedure bed was 10 min longer for MAC (102 vs. 92 min, P < 0.001, d = 0.22). Total IR encounter times were on average 27 min longer for MAC cases (231 vs. 204 min, P < 0.001, d = 0.41). Conclusion: MAC improves the utilization of IR procedure rooms, but at the cost of increased patient time in the pre- and post-procedure areas.

Randomized split-face study using a post-procedural biotech cellulose mask to improve patient comfort and downtime.

BACKGROUND: There are many post-procedural treatments touted to improve comfort and decrease downtime, but very few prospective randomized studies. AIMS: To analyze the safety and efficacy of a post-procedural biotech cellulose mask. PATIENTS/METHOD: Fifteen patients undergoing either a microneedling with radiofrequency (n = 5), non-ablative fractional (n = 5), or full erbium:YAG resurfacing (n = 5) treatment were randomized to receive a biotech cellulose mask on one side of the face for 30 min after the procedure and for 2 h a day until healed. Standardized photos and thermal images were taken 30 min after the procedure and daily until healed. The investigator and blind evaluators reviewed the photos, and subjects answered daily questionnaires. RESULTS: An analysis of the thermal images showed a significant reduction in facial temperature on the biotech cellulose mask side as compared to the control side in all groups with an average of 2.2 (range 0.2-6.5) degree Celsius reduction across all 15 subjects. All subjects reported less pain and heat immediately upon application of the mask. Thirty minutes after application, 13/15 continued to report less pain and heat, and 11/15 reported less erythema and swelling on the mask side while blind evaluators were able to choose which side had the mask 80% of the time. On average, subjects also reported significantly less swelling on Day 1 and Day 2. CONCLUSION: The biotech cellulose mask decreased patient's facial temperature, feelings of heat and pain, as well as downtime without any side effects for the subjects in this study undergoing a variety of treatments.

Comparison of outcomes between clipping and endovascular coiling in anterior choroidal artery aneurysm: a systematic review.

SAH (subarachnoid hemorrhage) caused by aneurysm rupture has the greatest mortality rate, with nearly 50% of patients unable to survive beyond 1 month after the attack. Anterior choroidal artery (AChA) aneurysms are one of the most difficult to treat among the numerous types of aneurysms. Until now, some neurosurgeons employed shearing while others employed coiling. In this trial, researchers will compare surgical clipping and endovascular coiling treatments for anterior choroidal artery aneurysms in terms of mortality, rebleeding, retreatment, and post-procedure outcomes. Using the PubMed electronic database, the Cochrane library, the Medline Database, the Directory of Open Access Journals, and EBSCHOHOST, a systematic review compared surgical clipping and endovascular coiling in all cases of choroidal artery aneurysm. There were 17 studies that met the eligibility requirements, with a total of 1486 patients divided into groups that underwent clipping (1106) or endovascular coiling (380). The mortality rate for clipping is 1.8%, while the mortality rate for endovascular coiling is 2.34%. Rebleeding occurs in 0% of patients undergoing endovascular coiling and 0.73% of patients undergoing clipping. Retreatment of clipping was 0.27%, while endovascular coiling was 3.42%. Post-complication procedures occurred in 11.12% of patients undergoing endovascular clipping and 15.78% of patients undergoing endovascular coiling. The intervention technique of clipping has a reduced rate of mortality, reoperation, and post-operative complications. Endovascular coiling results in a reduced rate of rebleeding than clipping.

Comparison of Adverse Events between Isolated Left Atrial Appendage Closure and Combined Catheter Ablation.

(1) Background: This study aimed to investigate the effect of an additional catheter ablation (CA) procedure on the risk of post-procedure adverse events during CA combined with left atrial appendage closure (LAAC). (2) Methods: From July 2017 to February 2022, data from 361 patients with atrial fibrillation who underwent LAAC at our center were analyzed retrospectively. The adverse events were compared between CA + LAAC and LAAC-only groups. (3) Results: The incidence of device-related thrombus (DRT) and embolic events was significantly lower in the CA + LAAC group than in the LAAC-only group (p = 0.01 and 0.04, respectively). A logistic regression analysis revealed that the combined procedure served as a protective factor for DRT (OR = 0.09; 95% confidence interval: 0.01-0.89; p = 0.04). Based on a Cox regression analysis, the risk of embolism marginally increased in patients aged ≥65 years (HR = 7.49, 95% CI: 0.85-66.22 p = 0.07), whereas the combined procedure was found to be a protective factor (HR = 0.25, 95% CI: 0.07-0.87 p = 0.03). Further subgroup and interaction analyses revealed similar results. (4) Conclusions: The combined procedure may be associated with a lower rate of post-procedure DRT and embolization without a higher occurrence of other adverse events after LAAC. A risk-score-based prediction model was conducted, showing a good prediction performance.

A Single Center, Prospective, Randomized, Blinded Study to Evaluate the Efficacy and Safety of a Topical Tripeptide/Hexapeptide Anhydrous Gel When Used Pre- and Post- Hybrid Fractional Laser for the Treatment of Acne Scars.

Background: Acne scarring remains a significant problem. Laser therapy has produced varying results with deeper ablative therapies occasionally associated with side effects including delayed healing, infection, scarring, erythema, acne, milia, edema and dyspigmentation. Objective: Can adjuvant topical therapy impact the healing process and outcome of patients treated with fractional laser for acne scarring? Methods and Materials: Ten patients were randomized to receive either Regenerating Skin Nectar with TriHex Technology®- RSN or a bland moisturizer. Patients underwent two laser procedures one month apart with Hybrid Fractional Laser. The topical was applied twice daily for 2 weeks prior to the first laser procedure, and through completion of the study. Seven study visits occurred over a 90-day period. Measurements were conducted in lesional and non-lesional areas - transepidermal water loss (TEWL), erythema, photography, Goodman and Baron qualitative scale, Global Aesthetic Improvement Scale and patient questionnaires - to assess functional recovery and aesthetic outcomes in the scarred areas. One patient from each cohort consented to biopsy before the procedures and 90 days after the first procedure. Results: Reduced TEWL scores in the RSN group were evident at all time points with statistically significant reductions occurring 4 days after first and second procedures indicating more efficient fluid conservation at a critical point in the healing trajectory. Erythema index demonstrated a consistent decrease in the RSN cohort over the control from day 4 through day 90 on lesional and non-lesional skin. Acne scar assessment scores improved in the RSN cohort compared with the control at all time points. Biopsy results showed early elastin regeneration in the RSN biopsy with controlled non-hypertrophic collagen formation evident. Conclusion: The use of RSN pre- and post- laser resurfacing significantly decreased postprocedural TEWL and erythema, and increased aesthetic improvement in acne scars and patient satisfaction, when compared with bland moisturizer.

Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database.

Introduction Paralytic ileus (PI) is often seen in critically ill hospitalized patients. Those with pancreaticobiliary diseases will require endoscopic retrograde cholangiopancreatography (ERCP) for management. Here, we will explore the association between patients with paralytic ileus who underwent ERCP and post-procedural complications, which has not been done before. Methods Patients who underwent ERCP between 2007 and 2017 in the National Inpatient Sample database were selected. Cases were matched 1:1 by age, gender, race, and the Elixhauser comorbidity index for patients with and without pre-procedural paralytic ileus. Primary outcomes were associations between paralytic ileus and length of stay, payor status, and average total charges. Secondary outcomes were associations between paralytic ileus and post-ERCP complications (infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage), and overall mortality. The Chi-squared analysis was used to compare categorical data, and the independent t-test was used for continuous data. Regression analysis was used to assess primary and secondary outcomes. Results Of 2,008,217 hospitalized patients from 2007 to 2017, 43,643 patients had paralytic ileus and 43,859 patients did not, before undergoing ERCP. There were no differences in age, gender, race, or the Elixhauser comorbidity index. The differences in the length of stay, payor status, and total charges were significant (p<0.001). Patients with paralytic ileus had increased risks of post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality (p<0.001). Conclusions Patients hospitalized with paralytic ileus who underwent ERCP had a longer length of stay, higher total charges, and were less compensable. They also had increased risks for post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality, which can be from critical illness and the systemic inflammatory response.

Incremental Healthcare Cost Implications of Retreatment Following Ureteroscopy or Percutaneous Nephrolithotomy for Upper Urinary Tract Stones: A Population-Based Study of Commercially-Insured US Adults.

Purpose: This study describes the incremental healthcare costs associated with retreatment among adults undergoing ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) for upper urinary tract stones (UUTS). Patients and Methods: The IBM® MarketScan® Commercial Database was used to identify adults aged 18-64 years with UUTS treated with URS or PCNL between January 2010 and December 2019. Patients had 12 months of continuous insurance coverage before (baseline) and after (follow-up) the first (index) procedure. The primary outcome was total all-cause healthcare costs measured over the 365-day follow-up period, not inclusive of index costs. Generalized linear models were used to estimate the incremental costs associated with retreatment within 90 (early) or 91-365 days post-index (later) relative no retreatment. The models adjusted for demographics, comorbidities, stone(s) location, treatment setting, procedural characteristics (eg, 1-step vs 2-step PCNL) and index year. Results: Approximately 23% (27,402/119,800) of URS patients were retreated (82% had early retreatments). The adjusted mean total cost was $10,478 (95% CI: $10,281-$10,675) for patients with no retreatment, $25,476 (95% CI: $24,947-$26,004) for early retreatment ($14,998 incremental increase, p<0.01), and $32,868 [95% CI: $31,887-$33,850] for later retreatment ($22,391 incremental increase, p<0.01). Approximately 36% (1957/5516) of PCNL patients were retreated (78% had early retreatments). The adjusted mean total cost was $13,446 (95% CI: $12,659-$14,273) for patients with no retreatment, $37,036 [95% CI: $34,926-$39,145]) for early retreatment ($23,570 incremental increase, p<0.01), and $35,359 (95% CI: $32,234-$38,484) for later retreatment ($21,893 incremental increase, p<0.01). Conclusion: Retreatment during the first year following URS or PCNL was needed in 23% and 36% of patients, respectively, and was associated with an economic burden of up to $23,500 per patient. The high rate of retreatment and associated costs demonstrate there is an unmet need to improve mid- to long-term results in URS and PCNL.

Staphylococcus aureus (S. aureus) Lobar Pneumonia Following Bronchoscopic Lung-Volume Reduction (BLVR): A Case Report and Review of Literature.

With the advent of bronchoscopic lung-volume reduction (BLVR), this minimally invasive technique represents a new and effective way of managing the debilitating symptoms associated with severe centrilobular emphysema. Despite its vast potential in the management of this disease, there are still several potential risk factors associated with the procedure that may predispose the patient to increased morbidity. Our patient received four endobronchial valves in the right-upper lobe (RUL) and right-middle lobe (RML). Although her immediate post-procedure course was uncomplicated, she returned shortly after discharge with a right-sided pneumothorax and right-lower lobar pneumonia with sputum culture growing methicillin-sensitive Staphylococcus aureus (S. aureus). She was managed with tube thoracostomy and two weeks of cefazolin with clinical improvement. Despite the abundance of literature detailing the risk of pneumonia following BLVR, very little data exists discussing common causative organisms, choice of treatment, duration of treatment, and potential risk factors that may predispose these patients to infection.

A Retrospective Review of the Safety and Efficacy of Low-dose Triamcinolone Mixed with Hyaluronic Acid Fillers to Reduce Post-injection Infraorbital Swelling.

Objective: This retrospective review assesses the efficacy and safety of low-dose triamcinolone (1mg/cc) added to hyaluronic acid fillers to decrease swelling after infraorbital injection. Methods: This retrospective analysis includes 447 patients who underwent 706 infraorbital hyaluronic acid filler treatments from April 2013 to March 2020 by a single injector. Short-term post-procedural swelling (≤2 weeks) was assessed through follow-up phone calls, which were documented in patient charts. The effect of triamcinolone, filler type, volume, and patient characteristics on the rate of post-procedure swelling were analyzed. Results: Swelling after infraorbital hyaluronic acid filler occurred in over half of the patients (51%, 103/202), but significantly decreased (23%, 29/124) when 1mg/cc of triamcinolone was mixed with the filler (x2[1, N=326]=24.296, p<0.00001). The incidence of swelling was directly correlated with the amount of hyaluronic acid filler injected (37% ≤ 0.55cc, 51% 0.56-1cc, and 60% >1cc) [x2[1, N=95]=3.9231, p=.048]. There was no significant difference in patient age, sex, Fitzpatrick skin type, or history of allergies on incidence of post-procedure swelling. Adverse events were limited to expected injection-site reactions, and there were no reports of hypopigmentation or atrophy from the addition of triamcinolone. Limitations: This is a retrospective study that used patient reporting for short-term post procedure swelling. Conclusion: This is the first retrospective study showing the safety and efficacy of a novel technique adding low-dose triamcinolone (1mg/cc) to hyaluronic acid filler to reduce post-procedure swelling within the first few weeks following infraorbital injection. Additionally, using lower volumes is also effective at reducing post-procedure swelling. Larger, randomized, controlled trials are needed to support our findings.

Post-procedure Rhinitis After Use of Sedatives and Supplemental Nasal Oxygen.

Post-procedure rhinitis is a form of nonallergic rhinitis that is a common but underreported complication occurring after procedures requiring sedation and the use of supplemental oxygen via nasal cannula. Symptoms occur immediately after awakening from sedation and may be so unbearable, that it impairs work, daily functioning, sleep patterns, and quality of life. This case describes a 67-year-old male who developed these symptoms after esophagogastroduodenoscopy (EGD) under sedation with supplemental oxygen via nasal cannula. The proposed pathophysiology is thought to be due to the impingement of the cannula against mechanoreceptors in the nasal mucosal membrane causing parasympathetic overactivity. Based on this pathogenesis, the reported patient failed to show improvement with oral antihistamines but instead benefited from a topical anticholinergic agent. Patients at risk should be informed of the possibility of this adverse event and advised on proper treatment if it occurs.

Recommendations for the use of corrective makeup after dermatological procedures.

INTRODUCTION: The number of dermatological or cosmetic procedures carried out has continuously increased over the last decades. Almost all may cause transient local skin reactions such as erythema, blistering, crusts, scaling, hypo- or hyperpigmentation, or hemorrhagic lesions. One issue of dermatological procedures is the downtime, during which patients need to hide their skin, due to these local reactions. AIM: To provide dermatologists with easy-to-follow recommendations for the right timing of use of corrective makeup for patients who have undergone or who plan to undergo dermatological procedures, according to the invasiveness of the dermatological procedure chosen. METHODOLOGY: A group of experts in dermatological procedures met in 2019 and at the beginning of 2020 to discuss the different procedures, their local reactions and downtime, and the opportunities to use specific corrective makeup in order to hide these transient reactions. RESULTS: As a result of the discussions, the experts proposed a tabulated algorithm of use based on a classification of the different dermatological procedures according to their invasiveness and recommended timing of the first post-procedure corrective makeup application. CONCLUSION: Corrective makeup may be considered as a complement to certain dermatological procedures in order to minimize downtime. However, its use is conditioned by the correct understanding of skin barrier alteration and recovery time. The proposed algorithm of use of corrective makeup after procedures may help the practitioner to indicate his patient the right moment for applying corrective makeup in order to avoid local tolerance issues and post-procedure complications.

Long-term visual outcomes of endophthalmitis and the role of systemic steroids in addition to intravitreal dexamethasone.

BACKGROUND: The purpose of this study was to evaluate the role of systemic steroids in post-procedural endophthalmitis as the role of intravitreal steroids in treatment algorithms of endophthalmitis remain controversial. METHODS: This is a retrospective analysis from a single tertiary referral center of all patients older than 18 years old that developed presumed post-procedure endophthalmitis and were treated at our center from 2009 to 2018. RESULTS: Eighty-three patients were followed after being treated for post-procedural endophthalmitis that either received systemic steroids or did not around the time of diagnosis. Almost 30 % of all patients regained a final visual acuity of 20/40 or better, while 31.2% had poor visual outcomes of count fingers or worse. Non-clearing debris was the most significant long-term complication. Visual improvement plateaued in 67.7% by 1 month after diagnosis and initial treatment in both groups. There was no difference in visual outcomes when comparing the sixteen patients that received systemic steroids and the sixty-seven that did not; however, no enucleation or evisceration was required in patients receiving systemic steroids. Five patients that did not receive systemic steroids required an enucleation or evisceration due to a blind, painful eye. CONCLUSIONS: The use of systemic steroids does not seem to worsen long-term outcomes of endophthalmitis compared to those patients that did not receive them and they may prove beneficial in the most severe cases by reducing the risk of losing the globe altogether.

Psychomotor Recovery Following Remimazolam-induced Sedation and the Effectiveness of Flumazenil as an Antidote.

PURPOSE: Remimazolam tosylate (HR-7056) is a novel ester-type benzodiazepine with ultrafast onset of effect. The compound is being developed for sedation induction and maintenance during anesthesia. It was approved for procedural anesthesia in December 2019 by the National Medical Products Administration of China. Previous studies have reported on remimazolam's effects on consciousness and cognition. Although the time to full psychomotor recovery after remimazolam-mediated sedation is critical for decisions regarding hospital discharge, relevant clinical evidence is still lacking. This study investigated the residual psychomotor effects of remimazolam and their recovery from sedating treatment in 2 simulated clinical settings: (1) single-dose administration for sedation initiation; and (2) constant rate infusion for sedation maintenance. METHODS: A single-ascending-dose, parallel-group, midazolam-controlled study and a 2-way crossover study evaluating the reversal effect of flumazenil versus placebo after a 2-h constant rate infusion were conducted with HR-7056 in 87 Chinese healthy volunteers; the studies used a double-blind, randomized trial design. A battery of psychomotor tests was administered before dosing and several times postdose over 4-6 h. Pharmacokinetic, sedation, and safety assessments were performed throughout the studies. FINDINGS: After bolus infusion, the Bispectral Index score decreased in a concentration-dependent manner with HR-7056, accompanied by a sharp drop of Modified Observer's Assessment of Alertness/Sedation score. The recovery of consciousness was much faster with HR-7056 than with midazolam. During the constant rate infusion, the Bispectral Index score was maintained between 40 and 60 with an average plasma remimazolam concentration of ~1000 ng/mL. Subjects' performance in saccadic and smooth pursuit eye movement, body sway, test of choice reaction time, and word recall was significantly impaired after single-dose midazolam and after constant rate infusion of remimazolam. The end-of-infusion injection of flumazenil shortened the median time to full alertness to 3.5 min and effectively reversed psychomotor and cardiovascular dysfunction. IMPLICATIONS: The study results showed quicker psychomotor recovery from sedation in the remimazolam-treated group. The moderate and short-lasting residual effect of remimazolam after 2-h conscious sedation proposes a need for psychomotor assessment(s) before hospital discharge. ClinicalTrials.gov identifiers: NCT01970072 and NCT03444480.

The efficacy of prophylactic pancreatic stents against complications of post-endoscopic papillectomy or endoscopic ampullectomy: a systematic review and meta-analysis.

BACKGROUND: Endoscopic resection has been increasingly adopted for neoplasms in the major duodenal papilla. Previous studies have reached varying conclusions on whether prophylactic pancreatic stent (PS) placement is an effective measure against post-procedure complications. We aimed to investigate whether PS could reduce the incidence of post-procedure complications. METHODS: The PubMed, Cochrane Library, and EMBASE databases were systematically searched from the inception dates to 25 December 2018 to identify all randomized controlled trials (RCTs) and retrospective cohort studies (RCSs) comparing prophylactic PS and no PS against post-procedure complications. The main outcomes measurements were post-procedure pancreatitis, bleeding, perforation and late papillary stenosis. RESULTS: 23 RCSs (1001 subjects) and 2 RCTs met the inclusion criteria. Meta-analysis of the RCSs showed that prophylactic PS decreased the odds of post-procedure pancreatitis (OR, 0.71; 95% CI, 0.36-1.40; p = 0.325) as well as late papillary stenosis (OR, 0.35; 95% CI, 0.07-1.75; p = 0.200; I 2 =0%) and increased the odds of bleeding (OR, 1.32; 95% CI, 0.50-3.46; p = 0.572; I 2 = 0%) and perforation (OR, 2.25; 95% CI, 0.33-15.50; p = 0.412; I 2 = 0%) but not significantly. Sensitivity analysis illustrated prophylactic PS significantly decreased the risk of post-procedure pancreatitis (OR, 0.44; 95% CI, 0.24-0.80; p = 0.007). CONCLUSIONS: PS placement was prophylactic against post-procedure complications although not significantly. Sensitivity analysis suggests the significant effect of prophylactic PS against post-procedure pancreatitis. More RCTs are required to validate the statistical significance of our results and potentially relevant characteristics improving the prophylactic efficacy of stents.

Current Endovascular Approach to the Management of Acute Ischemic Stroke.

PURPOSE OF REVIEW: The review provides an overview of current endovascular management of patients with acute ischemic stroke in the light of recent landmark trials proving unequivocal benefit of the intervention. RECENT FINDINGS: Several randomized trials looking at selective groups of patients presenting after an acute ischemic stroke due to large vessel occlusion in the anterior circulation demonstrated an overwhelming benefit of the endovascular treatment compared to intravenous thrombolysis, leading to expedited changes in the American Heart Association/American Stroke Association guidelines. Nonetheless, there are a relative large number of patients that were not included in those trials that might still benefit from endovascular treatment (acute posterior circulation-related strokes or acute embolic occlusion of middle cerebral artery beyond the main trunk for instances) and in which further studies are needed. We also briefly discuss endovascular techniques, post-procedure care, and endovascular treatment delivery models to expedite stroke patient assessment and rapid transport using updated and improved workflow protocols to provide timely recanalization. Endovascular treatment of acute occlusion of a proximal large artery in the anterior circulation is currently the standard of care. Time and quality of recanalization are the most important variables that determine the outcome. The indication for endovascular therapy in different scenarios (acute embolic occlusion in the posterior circulation or more distal branch occlusions) has to be individualized according to each patient's particular characteristics until new evidence is provided.

Post-polypectomy bleeding and thromboembolism risks associated with warfarin vs direct oral anticoagulants.

AIM: To verify the validity of the endoscopy guidelines for patients taking warfarin or direct oral anticoagulants (DOAC). METHODS: We collected data from 218 patients receiving oral anticoagulants (73 DOAC users, 145 warfarin users) and 218 patients not receiving any antithrombotics (age- and sex-matched controls) who underwent polypectomy. (1) We evaluated post-polypectomy bleeding (PPB) risk in patients receiving warfarin or DOAC compared with controls; (2) we assessed the risks of PPB and thromboembolism between three AC management methods: Discontinuing AC with heparin bridge (HPB) (endoscopy guideline recommendation), continuing AC, and discontinuing AC without HPB. RESULTS: PPB rate was significantly higher in warfarin users and DOAC users compared with controls (13.7% and 13.7% vs 0.9%, P < 0.001), but was not significantly different between rivaroxaban (13.2%), dabigatran (11.1%), and apixaban (13.3%) users. Two thromboembolic events occurred in warfarin users, but none in DOAC users. Compared with the continuing anticoagulant group, the discontinuing anticoagulant with HPB group (guideline recommendation) had a higher PPB rate (10.8% vs 19.6%, P = 0.087). These findings were significantly evident in warfarin but not DOAC users. One thrombotic event occurred in the discontinuing anticoagulant with HPB group and the discontinuing anticoagulant without HPB group; none occurred in the continuing anticoagulant group. CONCLUSION: PPB risk was similar between patients taking warfarin and DOAC. Thromboembolism was observed in warfarin users only. The guideline recommendations for HPB should be re-considered.

The acute effects of bronchial thermoplasty on FEV1.

BACKGROUND: The most common adverse effect of bronchial thermoplasty (BT) is short-term aggravation of asthma immediately following the procedure. However, the magnitude and duration of this deterioration, and its predisposing factors are yet to be quantitated. This information will be particularly important as BT is extended to include more severely obstructed patients. METHODS: In this prospective, observational study of 20 consecutive patients with very severe asthma undergoing BT, post bronchodilator FEV1 was measured in the 30 min prior to surgery, and then 24 h following the 60 procedures. In half the patients, further spirometry was conducted on day 3 and day 7 post procedure. RESULTS: This study enrolled 12 males and 8 females, mean age 59.7 ±â€¯12.8 years, with mean prebronchodilator FEV1 of 52.3 ±â€¯15.2% predicted, mean forced expiratory ratio of 51.4 ±â€¯12.6%, and mean improvement in FEV1 post salbutamol of 19.5 ±â€¯15.3%. All patients were taking inhaled corticosteroids, mean beclomethasone equivalent dose 1950 ±â€¯857 mcg, and 7 patients required maintenance oral corticosteroids for control of their asthma. Twenty four hours after BT, the mean deterioration in post bronchodilator FEV1 was 166 ±â€¯237 mls (CI 102-224, p < 0.001) or 9.1 ±â€¯15.2% of baseline. This deterioration was significantly greater after upper lobe procedures (p < 0.01, ANOVA repeated measures), where a mean fall in FEV1 of 17.1 ±â€¯12.6% was observed. The change in FEV1 post procedure was significantly correlated with the number of radiofrequency activations applied, r = -0.376, p < 0.005. By multivariate analysis, the only factor other than activations predictive of the change in FEV1 was age, which was protective. When the lower lobes were treated, the postbronchodilator FEV1 had returned to baseline values by day 3, but patients took 7 days to recover after upper lobe treatments. Despite the severity of asthma in these patients, and the measured deterioration post treatment, there was only one instance of readmission in the 60 procedures. CONCLUSIONS: The deterioration in lung function after BT is transient and well tolerated, but is greatest after upper lobe treatment, and is significantly related to the number of radiofrequency activations applied.